November, 2000

Information Bulletin 00-32
NH-55

Calls To Providers
State And Federal Regulations Pertaining To Resident Status

AN UPDATE FROM COLLEEN COOPER, M.D., MEDICAL ADVISOR
MINNESOTA DEPARTMENT OF HEALTH

The Minnesota Medical Director's Association (MMDA) has raised the issue of after hour phone calls to providers (physicians, nurse practitioners and physician's assistants.) MMDA has asked for clarification of the existing regulations . The Minnesota Department of Health is pleased to provide clarification of the relevant state and federal requirements in the hope that effective communication between nursing facilities and providers will improve care for residents.

The Minnesota regulations, revised in 1996 state:

A nursing home must develop and implement policies to guide staff decisions to consult physicians, physician assistants, and nurse practitioners, and if known, notify the resident's legal representative or an interested family member of a resident's acute illness, serious accident, or death. At a minimum, the director of nursing services, and the medical director or an attending physician must be involved in the development of these policies. The policies must have criteria which address at least the appropriate notification times for:

  1. An accident involving the resident which results in injury and has the potential for requiring physician intervention;

  2. A significant change in the resident's physical, mental, or psychosocial status, for example, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications;

  3. A need to alter treatment significantly, for example, a need to discontinue an existing form of treatment due to adverse consequences, or to begin a new form of treatment;

  4. A decision to transfer or discharge the resident from the nursing home; or

  5. Expected and unexpected resident deaths

The relevant federal regulations (tag F157) requires facilities to notify the physician when:

  1. An accident involving the resident which results in injury and has the potential for requiring physician intervention;

  2. A significant change in resident's physical, mental or psycho social status.

Neither state nor federal regulations require that providers be called about falls when no injury has occurred. The federal regulations default to the state laws regarding physician notification of a resident's death. In Minnesota, each facility may develop its own policies regarding when to contact a physician regarding a resident's death whether expected or unexpected.

Falls

After a fall, residents must be assessed for injury. Evidence of injury might include: unstable or significantly changed vital signs, more than mild pain, altered range of motion, laceration, hematoma, functional change, bleeding and changed level of consciousness. If the nursing staff find no significant evidence of injury, facility policy may direct staff to continue to observe and monitor. This is consistent with current standard of practice. There is no regulatory mandate to contact the resident's provider. If the resident develops a change of condition after the fall or during the period of observation, the provider should be contacted at that time. If the fall suggests a change of condition for that resident, the provider should be contacted.

Deaths

Facilities may develop policies that allow physicians to be notified of expected resident deaths during clinic hours. For example, if a resident is in the terminal stage of an illness and death is expected, the facility may have a policy which allows for release of the body to the funeral home at the time of death with next day notification of the attending physician. Alternatively when death is expected for a specific resident, the attending physician may write an order for release of the body with physician notification the following day. Off hour calls to providers will often result in notification of the on-call service who will have little direct knowledge of the individual. If the death is unexpected or occurs in the context of unusual circumstances, the attending or on-call physician should be notified immediately.

Survey Experience

Facilities and medical staff must work together to develop workable and effective modes of communication. Calls to providers when there is no need for intervention or guidance don't foster effective communication, nor do these calls prevent adverse survey outcomes. For example, if a resident falls, a call to the provider would be expected if after nursing staff assessment, an acute injury or change of condition is noted and the provider's guidance is needed for additional evaluation or treatment. If there is not injury or change of condition, a call may not be necessary unless the individual later develops signs or symptoms suggesting a possible injury. In summary, phone calls to providers should be tied to patient needs, not to what is often misunderstood as a regulatory requirement.

There is a concern among facilities that failure to call about all falls will result in deficiencies. The relevant regulation is 42 CFR 483.10(b)(11), tag F157. In the past year (July 1999-July 2000,) nineteen deficiencies have been issued at F157. Of these, fifteen were at a level D scope and severity (potential for harm at an isolated level) and four were at level G (actual harm at an isolated level.) None of these deficiencies were related in any way to calls made on routine calls with no injury or change of condition. None cited the facility for failing to notify the provider of an expected death.

Summary

State and federal regulations were written with the intent of providing adequate care to residents of nursing homes. There is no mandate for routine calls to providers to report uneventful falls or expected deaths. Nursing facilities are encouraged to develop notification policies that ensure adequate care of its residents and avoid unnecessary contacts. Involvement of the facility medical director and attending providers may enhance the development of facility policies regarding provider notification, enhance cooperation and, most importantly, enhance patient care.

If you have any questions regarding this Information Bulletin, please contact in writing:

Minnesota Department of Health
Compliance Monitoring Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900
St. Paul, Minnesota 55164-0900
Telephone: (651) 201-4101.

Updated Friday, 25-Mar-2011 14:28:04 CDT